Neuroanaesthesia04 / 14
Refractory status epilepticus after missed antiseizure drugs27-year-old man, 78 kg, brought to the emergency department fitting for 25 minutes
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Know this first
- Seizures that run past 5 minutes rarely end without treatment.
- Refractory: seizures persist after a benzodiazepine and one second-line drug.
- Second line: fosphenytoin, valproate or levetiracetam; third line: midazolam or propofol infusion.
- Avoid long-term paralysis: it hides ongoing seizures.
- Valproate: thrombocytopenia and more surgical bleeding.
The patient
27-year-old man, 78 kg, brought to the emergency department fitting for 25 minutes.
Known epilepsy on carbamazepine and valproate; missed doses for 3 days. Platelets 85 × 10⁹/L last month.
Given lorazepam 4 mg IV twice; still in generalised tonic-clonic seizures. Glucose not yet checked.
Vitals: BP 164/96, HR 132, SpO2 88% on 15 L/min mask, RR 32, temperature 38.0 °C.
The examiner asks
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Consider
What are your priorities?
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- A 27-year-old in convulsive status after missed doses, still fitting after two benzodiazepine doses. Patient
- He's at 25 minutes; past 5 minutes a seizure rarely stops on its own. Disease
- Airway, oxygen and circulation first; his SpO2 is 88%. Airway
- Bedside glucose now; dextrose only if it's low, as high glucose harms the brain. Disease
- His triggers: missed doses, low sodium from carbamazepine, infection with this fever. Stem trigger
- Valproate may have dropped his platelets; I check the count and clotting. Disease
Plan
He is still fitting. What is your plan?
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- Second-line now: an IV loading dose of fosphenytoin. Disease
- Valproate or levetiracetam are the alternatives; he's already on valproate.
- If fits continue, it's refractory status: intubate and start an anaesthetic infusion.
- Carbamazepine shortens the effect of non-depolarisers.
- Sodium, drug levels, CK and cultures sent; ICU bed booked. After surgery
Crisis
Ten minutes after fosphenytoin he is still fitting; SpO2 84%, HR 140, BP 170/100. What do you do?
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- Refractory status: third-line drugs mean intubation and ventilation now. Crisis
- RSI with propofol, which also halts seizure activity during intubation. Airway
- Suxamethonium 1.5 mg/kg, so paralysis wears off and seizures show again.
- Then propofol 1–2 mg/kg and 150 mcg/kg/min, titrated to burst suppression. Crisis
- Continuous EEG, because seizures can carry on without movement.
- No long-acting relaxant; it would mask recurrent seizures.
- Treat what drives it: glucose, temperature, sodium; then ICU. After surgery
Crisis
Right after intubation you suction gastric fluid from the tube; SpO2 82% on 100% oxygen, with wheeze. What do you do?
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- Aspiration during the fits or at intubation. Crisis
- Suction down the tube on 100% oxygen before ventilating harder.
- Oxygen plus PEEP is the best treatment for the pneumonitis.
- Bronchoscopy to look for and remove any solid material.
- A clear chest X-ray now doesn't exclude it; changes may take 6–12 hours.
- Ventilate in ICU on EEG; his seizures still need control. After surgery
Fatal mistakes
- Long-acting paralysis without EEG, hiding seizures.
- No glucose check.
- Delaying escalation to third-line therapy.
Checked against: Miller 10e · Stoelting 8e · Faust · Barash 9e
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